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ORIGINAL ARTICLE

Medulloblastoma: A common pediatric tumor:

Prognostic factors and predictors of outcome
Lachi Pavan Kumar, Syed Fayaz Ahmed J. Deepa, I. Moinca, P. Suresh, K. V. J. R. Naidu
Department of Radiation Oncology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India

ABSTRACT
Background: Medulloblastoma is a common malignancy in the pediatric population, accounting for 25% of all childhood
brain tumors and relatively uncommon in adults. This review was to investigate treatment outcome and prognostic factors
after treatment of medulloblastoma.
Materials and Methods: Atotal of 53patients with histological confirmed medulloblastoma cases treated at our institute
between 2006 and 2012 were included in the study. Demographic variables, clinical variables, radiological findings and
treatment details with respect to age, sex, signs and symptoms, location of tumor, extent of surgical resection, histopathology
type, radiotherapy dose, followup period and outcomes were recorded. Survival was analyzed by using these parameters.
Results: Thirtyone (58.5%) patients were pediatric (<14 years), and 22 (41.5%) patients were adults (14 years).
Duration of symptoms were<3months in 19(36%) and more than 3months in 34(64%) patients. Tumor resection was
performed in all patients with gross total resection in 8(15%) patients, near total resection in 34(64%) patients and
subtotal resection in 11(21%) patients. All patients underwent postoperative craniospinal irradiation(CSI) delivering a
median craniospinal dose of 36Gy with additional boosts to the posterior fossa up to 54Gy. Median overall survival was
50months for the total group whereas 36months for pediatric age group and 70months for adult group. Desmoplastic
histology showed an improved outcome compared with other histologies with a median survival of 71months compared
with that of classical medulloblastoma histology being 36months and other histologies shown a median survival of 34 only.
Conclusions: Treatment of medulloblastoma with surgery and CSI yields long survival rates in both children and adults.
Adult age group and desmoplastic histology were associated with a favorable outcome.
Key words:Desmoplastic medulloblastoma, medulloblastoma, pediatric brain tumor

Introduction
Medulloblastoma is a common malignancy in the pediatric
population, accounting for 25% of all childhood brain tumors.[1]
Originally classified a glioma, medulloblastoma is referred
to now as a primitive neuroectodermal tumor. It is a highly
invasive tumor arising from the cerebellum with tendency to
disseminate throughout the central nervous system(CNS) early
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DOI:
10.4103/1793-5482.151516

Address for correspondence:

Dr.Lachi Pavan Kumar, Department of Radiation Oncology,

Nizams Institute of Medical Sciences, Hyderabad,
Telangana500082, India.
Email:drpavan.lachi@gmail.com

Asian Journal of Neurosurgery

Vol.10, Issue 1, JanuaryMarch 2015

in its course. The median age of diagnosis is 5years, with 80%

of cases being diagnosed in the first 15years. Aretrospective
analysis of our operated series of medulloblastoma was carried
out to study the various clinicoradiological features and overall
surgical outcome. An attempt was made to identify predictors
of poor outcome and to assess patterns of relapse.

Materials and Methods

Fiftythree patients with histological confirmed
medulloblastoma cases were treated at our institute
of between 2006 and 2012 were included in the study.
Demographic variables, clinical variables, radiological findings
and treatment details with respect to age, sex, signs and
symptoms, location of tumor, extent of surgical resection,
histopathology type, radiotherapy (RT) dose, follow-up period
and outcomes were recorded.

Statistical analysis
Descriptive and inferential statistical analysis has been
carried out in this study. Results on continuous measurements
are presented on mean standard deviation (min-max)

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Kumar, etal.: Medulloblastoma prognostic and predictors of outcome

and results on categorical measurements are presented

in number (%). Significance is assessed at 5% level of
significance. The following assumptions on data is made,
assumptions: (1) Dependent variables should be normally
distributed, (2) Samples drawn from the population should
be random, cases of the samples should be independent.
Students t-test (two-tailed, independent) has been used to
find the significance of study parameters on a continuous
scale between two groups (intergroup analysis) on metric
parameters. Chi-square/Fisher exact test has been used to find
the significance of study parameters on the categorical scale
between two or more groups. KaplanMeier function was used
to find the significance of survival in months according to age.
Significant figures + suggestive significance (0.05< P<0.10),
*moderately significant (0.01< P 0.05), **strongly significant
(P 0.01). Statistical software: The statistical software namely
SAS 9.2, SPSS version 15.0, Stata 10.1, MedCalc 9.0.1, Systat
12.0 and R environment ver.2.11.1 were used for the analysis
of the data and Microsoft word and Excel have been used to
generate graphs, tables etc.[2-5]

All patients underwent postoperative craniospinal

irradiation(CSI) delivering a median craniospinal dose of
36Gy with additional boosts to the posterior fossa up to
54Gy and adjuvant chemotherapy. On followup one patient
was developed spinal metastasis. After detection of spinal
metastasis this patient subsequently was subjected to
chemotherapy. Acomparison between the adult and pediatric
population is given in[Tables16]. The following variables
were assessed by bivariate analysis for adult and pediatric
study groups: Age, sex, duration of symptoms, location of the
lesion, brainstem invasion, extent of surgical excision of the
tumor, histological subtype.

Results

Table2: Gender distribution of patients studied

Thirty-one (58.5%) patients were pediatric (<14years), and

22 (41.5%) patients were adults (14 years). Duration of
symptoms were <3months in 19(36%) and more than 3months
in 34(64%) patients. Vomiting was present in 47(90%) cases,
23(42%) had visual blurring and 23(40%) presented with
diplopia. Cerebellar symptoms in the form of gait unsteadiness
were present in 36(69%). History of seizures or loss of
consciousness was present in 12(23%) patients. Cranial nerve
palsies were seen in 23(42%) patients and 21patients (40%)
had nystagmus. While 6patients presented with hemiparesis,
cerebellar signs were observed in 48patients. All patients
underwent preoperative magnetic resonance imaging (MRI)
scan of head. The postoperative analysis however was only
on the basis of computed tomography scan. MRI was done
in few patients postoperatively, but all the films could not
be retrieved and hence was not included in the study. The
tumor was located in midline in 37patients and periphery in
17patients. Calcification was observed in 10cases(18.8%).
MRI showed hydrocephalus in 42cases(79%). MRI evidence
of brainstem infiltration was present in five cases(9.4%). All
patients underwent surgical excision of lesion. Tumor resection
was performed in all patients and gross total resection in 8(15%)
patients, near total resection in 34(64%) patients and subtotal
resection in 11(21%) patients. Thirtytwo patients(60%)
required external ventricular drain in the perioperative
period. Histopathological examination showed classical
medulloblastoma in 33cases(62.3%), while desmoplastic variant
was observed in 16(30%) cases. Other histopathological variants
include anaplastic large cell variant in two cases(3.8%) and
nodular variant in two cases(3.8%). Operative complications
included gait unsteadiness in 15cases(19%).

Table1: Age distribution of patients studied

Age in years

Number of patients(%)

<14years
14years
Total

31(58.5)
22(41.5)
53(100.0)

MeanSD=13.307.78. SDStandard deviation

Gender
Female
Male
Total

Number(%)
Total

Age<14years

Age14years

19(35.8)
34(64.2)
53(100.0)

9(29.1)
22(70.9)
31(100.0)

10(45.5)
12(54.5)
22(100.0)

P=0.219

Table3: Duration of symptoms

Duration of
symptoms

Total

Age<14years

Number(%)
Age14years

<3 months
3 months
Total

19(35.8)
34(64.2)
53(100.0)

9(29.1)
22(70.9)
31(100.0)

10(45.5)
12(54.5)
22(100.0)

P=0.219

Table4: Lesion site involved of patients studied

Lesion site
Mid line lesion
Peripheral lesion
Total

Number(%)
Total

Age<14years

Age14years

37(69.8)
16(30.2)
53(100.0)

22(70.9)
9(29.1)
31(100.0)

15(68.2)
7(31.8)
22(100.0)

P=0.828

Table5: Surgery done

Surgery done
NTE
STE
GTE
Total

Number(%)
Total

Age<14years

Age14years

34(64.2)
11(20.8)
8(15.1)
53(100.0)

19(61.2)
9(29.1)
3(9.7)
31(100.0)

15(68.2)
2(9.1)
5(22.7)
22(100.0)

P=0.129. NTENear total excision; STESub total excision; GTEGross total

excision

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Kumar, etal.: Medulloblastoma prognostic and predictors of outcome

Median overall survival was 50months for the total group

whereas 36months for pediatric age group and 70months for
adult group[Figure1, Table7 and 8]. Desmoplastic histology
showed an improved outcome compared to other histologies
with median survival 71months compared to classical
medulloblastoma histology median survival 36 and other
histologies median survival 34months[Figure2]. Other factors
include durations of symptoms, sex, location of the tumor
and extent of surgical resection did not have any statistically
significant effect on the outcome in our series.[6-9] The effects
of RT in outcome were difficult to assess as all the patients
received the same dose.

Discussion
Medulloblastoma is the most common malignant brain
tumor of childhood, accounting for 2025% of pediatric
CNS neoplasms. Medulloblastomas are undifferentiated
embryonal neuroepithelial tumors of the cerebellum[10] arising
predominantly from the cerebellar vermis and primarily
affecting children in the first decade of life. The cell of
origin and the exact histological classification of this highly
malignant tumor are still controversial.[11]
Table6: Postoperative HPE
Postoperative HPE

Number(%)
Total

Classical medulloblastoma
33(62.3)
Desmoplastic medulloblastoma 16(30.2)
Large cell medulloblastoma
2(3.8)
Nodular medulloblastoma
2(3.8)
Total
53(100.0)

Age<14years Age14years
28(90.3)
1(3.2)
1(3.2)
1(3.2)
31(100.0)

5(22.7)
15(68.2)
1(4.5)
1(4.5)
22(100.0)

Classical medulloblastoma are significantly more associated age<14years with

P<0.001

Table 7: Survival in months**

Survival in
months

Total

Age<14years

Number(%)
Age14years

20-24
25-36
37-48
48-60
61-72
>72
Total
MeanSD

2(3.8)
22(41.5)
5(9.4)
8(15.1)
8(15.1)
8(15.1)
53(100.0)
49.2219.01

1(3.2)
18(58.1)
4(12.9)
6(19.4)
1(3.2)
1(3.2)
31(100.0)
40.5812.61

1(4.5)
4(18.2)
1(4.5)
2(9.1)
7(31.8)
7(31.8)
22(100.0)
61.4120.07

Although the majority cases occur as sporadic cases, hereditary

conditions have been associated with medulloblastoma,
including(1) gorlin syndrome(nevoid basal cell carcinoma
syndrome)(2) blue r ubberbleb nevus syndrome,
(3) Turcot syndrome(e.g.glioma polyposis syndrome)
and(4) RubensteinTaybi syndrome. The most frequent
cytogenetic abnormality in sporadic medulloblastoma is an
isochromosome 17q[12] of tumors analyzed, 4050% have a
deletion of the short arm of chromosome 17, implicating the
presence of a tumour suppressor gene that maps to 17p, which
is distinct from the p53 gene. These p53 mutations may be
important in the pathogenesis of human medulloblastoma.[13]
Gender is a debatable prognostic factor in pediatric series. Weil
etal.[14] and Prados etal.[15] found female gender to be a significant
favorable prognostic factor in medulloblastoma. Sex did not reveal
any bearing on the outcome in our series. Complete resection
should be performed if possible as several studies have correlated
outcome with extent of resection and amount of residual tumor.
[16]
In our pediatric population, near total to near total excision
of the lesion could be performed in 74.6%. We noted a lesser
incidence of the brain stem infiltration in our series, unlike
Packer RJ etal.[17] who found 36% of patients with radiological
evidence of brainstem infiltration. Brain stem infiltration could
be one of the major reasons of a relatively high incidence of
subtotal excision in our series. However, infiltration of the brain
stem glioma not effected survival in our series. Histopathological
examination of tumor in the present study showed clear
predominance of classical medulloblastoma in children. Available
literature suggests desmoplastic histological variant to be of
favorable prognostic significance.[18,19] Our series too could
establish a statistically significant correlation with a better
outcome in children having desmoplastic medulloblastoma.
Transcriptional profiling studies of medulloblastoma cohorts
from several research groups around the globe have suggested
the existence of multiple distinct molecular subgroups that
differ in their demographics, transcriptomes, somatic genetic
events, and clinical outcomes. Variations in the number,

Mean survival time in months is significantly less in age<14years with **P<0.001.

SDStandard deviation

Table8: Survival analysis

Age in years
<14years
14years

Mean

Median

Estimate

SE

Estimate

SE

40.58
61.41

2.63
4.28

36.00
70.00

0.49
1.81

Log rank test=19.871; P<0.001. SEStandard error

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Vol.10, Issue 1, JanuaryMarch 2015

Figure 1: Survival analysis according to age groups

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Kumar, etal.: Medulloblastoma prognostic and predictors of outcome

outcome determinants like extent of excision and residual tumor

did not show any correlation with outcome in our series.

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Figure 2: Survival analysis according to Histology

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Conclusions
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How to cite this article: Kumar LP, Deepa SJ, Moinca I, Suresh P,
Naidu K. Medulloblastoma: A common pediatric tumor: Prognostic
factors and predictors of outcome. Asian J Neurosurg 2015;10:50 51.
Source of Support: Nil, Conflict of Interest: None declared.

Asian Journal of Neurosurgery

Vol.10, Issue 1, JanuaryMarch 2015